“R” Children Child Development Laboratory

Afterschool Program
Supervising Teacher: Tom Rane

Emergency Contact Information

LAST NAME Child’s Name Address Phone Emergency Contacts &
Parents’ Name Numbers Phone Numbers
 Check In/Out Form
Afterschool 3rd-4th
Today’s Date: Dec. 12, 2018

Child’s Name Check In Check Out Comments

 Child Record Summary
Lab _____ Supervisor ____________________ “R” Children Preschool
Immun. Immun. Insurance Indemni- Emergency Photo Parent Parent Allergies/Health Concerns
Record Deficient Inform. fication Contact Consent Involve- Involve- Other Information/ Comments
Clause Informatio Option ment ment
Signed n Provided Option Completed
X=completed List them X=have X=completed X=completed List number List number Date
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X X X X X
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X X X X X Gluten intolerant
X X X X X
X X X X X
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X X X X X
--- --- --- --- Asthma
X X X X X
X X X X X
X X X X X
X X X X
X X X X X Lactose Intolerant
Testing for celiac
No grapes unless wash well
Self-esteem issues
X X X X
X X X X
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X X X X
X X X
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